Báo cáo y học: "Management of severe crush injury in a front-line tent ICU after 2008 Wenchuan earthquake in China: an experience with 32 cases" pot

Establishment of a well-equipped front-line ICU close to the epicentre of the earthquake allows for prompt on the spot rescue of critical patients with crush injury, greatly decreasing t

Open Access

Vol 13 No 6

Research

Management of severe crush injury in a front-line tent ICU after

2008 Wenchuan earthquake in China: an experience with 32 cases

Wenfang Li1, Jun Qian2, Xuefen Liu1, Qiang Zhang1, Lv Wang1, Dechang Chen1 and Zhaofen Lin1

1 Emergency Department, Changzheng Hospital, Second Military Medical University, No 415 Fengyang Road, Shanghai 200003, China

2 Intensive Care Unit, The People's Hospital of Jiangyou, No 346 middle Jinlun Road, Jiangyou City, Sichuan Province, 621700, China

Corresponding author: Zhaofen Lin, linzhaofen2009@yahoo.com.cn

Received: 22 Mar 2009 Revisions requested: 6 May 2009 Revisions received: 4 Oct 2009 Accepted: 6 Nov 2009 Published: 6 Nov 2009

Critical Care 2009, 13:R178 (doi:10.1186/cc8160)

This article is online at: http://ccforum.com/content/13/6/R178

© 2009 Li et al.; licensee BioMed Central Ltd

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction The experience on management of crush injury

after a devastating earthquake is lacking, and there are even less

reports on the line critical care of these patients A

front-line intensive care unit (ICU) was set up in a tent after the

disastrous Wenchuan earthquake (May, 12, 2008, China),

where 32 patients suffering from crush injury were treated from

May 12 to May 26 This study summarized our experience on

management of 32 crush injury patients in a front-line tent ICU

Methods We retrospectively analyzed the clinical data of 32

crush injury patients treated in our frontline tent ICU Using

limited equipment, we observed the arterial blood gas

parameters, blood routine, alanine aminotransferase, lactate

dehydrogenase, creatine kinase, creatinine, blood urea nitrogen,

and urine protein of patients We also closely watched for

changes in crush injury symptoms, urine output, and the

dangerous complications of crush injury

Results Eighteen of the 32 patients developed traumatic shock,

9 had acute renal failure, 6 had acute heart failure, 2 had stress

ulcers and 4 had multiple organ dysfunction syndrome (MODS)

The symptoms of 17 patients met the criteria of crush syndrome; hemodialysis and prompt surgical intervention were given to them when necessary Prompt treatment in our tent ICU improved the symptoms of patients to different degrees The limb distension and sensory dysfunction were improved and the urine output was increased or even restored to the normal level

in some patients Serological parameters were improved in most patients after admission Five (15.63%) patients underwent amputation due to severe infection in our group Six (18.75%) patients died, 4 due to MODS and 2 due to acute renal failure

Conclusions Severe crushing injuries and life-threatening

complications are major causes of death after major disasters like earthquakes Prompt treatment and close monitoring of the severe complications are of great importance in saving patients' lives Establishment of a well-equipped front-line ICU close to the epicentre of the earthquake allows for prompt on the spot rescue of critical patients with crush injury, greatly decreasing the mortality rate and complications and avoiding amputation There should be sufficient equipment to meet the needs of more patients

Introduction

Disasters such as earthquake, debris flow and landslide can

cause mass casualties In addition to direct injuries to vital

organs, such as the head and heart and rupture of large

ves-sels, crush injuries caused by prolonged pressing of the body

by collapsed buildings are also major causes of death The

acute increase of muscle pressure can lead to compartment

syndrome, clinically manifested as progressive swelling of the

involved limbs, great pain, diminishing sensory abilities and

muscle strength, and even paralysis [1-3] When exacerbated

swelling of body parts, acute renal failure (ARF), shock, or

hyperpotassemia is developed, crush syndrome is due to occur The incidence of crush syndrome is 2% to 15% in all trauma patients, and it can be as high as 30% in earthquake victims The symptoms of crush syndrome can last for three to five days in mild cases and for one to two weeks in severe cases About half of the victims develop ARF and the number

is almost 100% in those whose symptoms last for 40 hours; among the latter about 50% need hemodialysis The mortality

of patients with crush syndrome can be as high as 40% if the condition lasts for over three weeks [4-8]

ALT: alanine aminotransferase; APE: acute pulmonary edema; ARF: acute renal failure; BUN: blood urea nitrogen; CK: creatine kinase; HR: heart rate; ICU: intensive care unit; LDH: lactate dehydrogenase; MODS: multiple organ dysfunction syndrome; RR: respiratory rate; SU: stress ulcer.

The intensive care unit (ICU) is a setting equipped with

spe-cially trained medical professionals as well as advanced

mon-itoring system and first aid materials The aim of an ICU is to

monitor and treat patients with critical conditions such as

mul-tiple injuries, severe infections, shock of various origins, acute

organ failure and disorders of the internal environment of

patients Intensive care reflects the administration proficiency

and medical technology advancement of hospitals [9-11]

Close monitoring of pediatric patients [12], aged patients [13]

and patients with unstable vital signs can greatly improve their

survival rate [14-16] ICU plays an unreplaceble role in saving

the lives of victims after major disasters such as earthquakes,

especially those with crush syndrome and complications

[17-19] Demirkiran and colleagues considered that immediate

intensive care is vital to the survival of patients with crush injury

and compartment syndrome [20]

On 12 May, 2008, a catastrophic earthquake measuring 8.0

on the Richter scale struck the Wenchuan region of Sichuan

province, China, causing about 90,000 deaths and even more

injuries The rescue efforts were greatly hampered by the

mountainous terrain and damaged roads Many victims

devel-oped critical crush injury and compartment syndrome after

their limbs were pressed for a long time during entrapment

Our group, as part of the rescue team of the Second Military

Medical University, was sent to Jiangyou city, a severely hit

area labouring the most severely struck Beichuan Area A field

hospital was set up in the People's Hospital of Jiangyou, which

had been severely damaged during the earthquake We

res-cued some undamaged equipment from the severely

dam-aged ICU building and established a front-line tent ICU From

12 to 26 May, 32 patients with crush injury were treated in our

front-line tent ICU In this paper we reported the treatments

and outcomes of the 32 patients and summarize our

experi-ence in the front-line tent ICU

Materials and methods

Establishment of the front-line tent ICU

Using the undamaged equipment rescued from the collapsing

hospital buildings of the People's Hospital of Jiangyou, we

established a front-line tent ICU, as a unit of the field hospital

set up by the rescue team of the Second Military Medical

Uni-versity The ICU had four beds, each equipped with a monitor

(DASH3000, GE Company, Connecticut, USA), manual

respi-rator (LVT1000, Newport Corporation, Minnesota, USA) and

suction apparatus (YB DX23D, Shanghai Medicals

Corpor-tion, Shanghai, China) Other equipments included a blood

fil-trum (Prisma Machinegambro, Lund, Swede), a blood gas

analyzer (GEMPremier3000, Hartwell, Georgia, USA), a

bio-chemistry inspectoscope (CELLDYN3700, Abbott

diagnos-tics division, Chicago, Illinois, USA), a defibrillator

(HEARTSTART XL, PHILIPS, Boblingen, Germany) a trachea

cannula and breathing sacculus (GaleMed MR-100, Shanghai

Medicals Corportion, Shanghai, China), as well as routine

emergency drugs

General information of patients

From 12 to 26 May, a total of 32 patients were admitted to our front-line tent ICU, including 21 males and 11 females, with a mean age of 45 ± 19 years (range 13 to 56) Physical exami-nations upon admission were: the mean body temperature, 37.2 ± 0.6°C (range 36.3 to 37.6); the mean heart rate, 115.3

± 25.6 beats/min (range 85 to 142); mean respiratory rate, 26.9 ± 5.7 breaths/min (range 21 to 38); mean systolic blood pressure, 121.7 ± 21.3 mmHg (range 78 to 153), and mean diastolic blood pressure, 59.4 ± 16.8 mmHg (range 42 to 96)

Injuries of patients

Twenty-seven of the 32 patients had multiple injuries and five had lower limb injuries Nine patients had unilateral lower extremity trauma and 13 had bilateral ones Three patients had single femoral fractures and seven had bilateral femoral frac-tures Thirteen patients were complicated by pelvic fractures,

11 had chest trauma, 8 had cerebral trauma, 6 had splenic rupture, 5 had open tibia fracture, 5 had spinal injuries, and 3 had perinephrium and retroperitoneal hematoma The mean entrapment period of the patients was 3l ± 12 hours, ranging from 2 to 121 hours All the patients had swelling and disten-sion of extremities, various degrees of dysesthesia and dysci-nesia Twenty-three patients had soy sauce urine (indicating hemoglobinuria) Seven suffered from anuria and six from pink foam phlegm (a symptom of acute pulmonary edema) The clinical details of the 32 patients are given in Table 1 Informed consents were obtained from each patient or their guardians, and ethical approval was obtained from the Medical Ethics Committee of Changzheng Hospital, the Second Military Med-ical University

Laboratory tests

Due to the limited equipments, the parameters we could obtain included partial pressure of arterial oxygen, partial pres-sure of carbon dioxide, PH value, and base excess Other parameters included blood cell count, serum alanine transam-inase (ALT), serum lactate dehydrogenase (LDH), serum cre-atine kinase (CK), serum creatinine, serum urea nitrogen (BUN), and urine protein Upon admission the blood test showed the following results:blood hematocrit 39.6 ± 13.4% (range 23 to 52), leukocytes 21,562 ± 8765 cells/μL (range 12,300 to 32,500), platelets 136,775 ± 56,745 cells/μL (range 400,000 to 240,000)

Diagnosis and treatment of patients with crush syndrome

Crush syndrome is systemic manifestations characterized by swelling and distension of limbs, dyscinesia, myoglobinuria, and hyperpotassemia, usually caused by prolonged pressing

of body parts The mortality rate of patients with crush syn-drome could be as high as 50% to 70% Crush synsyn-drome can

be diagnosed when a crush injury patient develops systemic manifestations such as shock, acidosis, and ARF [21-23]

Table 1

Clinical details of the 32 patients in our group

Patient

Number

Protei-nuria Entrapment time

1 Chest trauma, left humerus fracture and right

radius fracture

3 Fracture of shaft of right femur, pelvic fracture, and

splenic rupture

4 Brain trauma, pelvis fracture, fracture of hypomere

of left femur, and right fibula fracture

5 Chest trauma, left humeral fracture, right ulna

fracture, splenic rupture

6 Left shaft of femur fracture and left tibiofibula

fracture

8 Brain trauma, pelvic fracture, left femoral neck

fracture, and right sprained knee

9 Chest trauma, fracture of shaft of left humerus,

right ulna and radius fractures

10 Brain trauma, hemopneumothorax, left shoulder

blade fracture, and sprain of left shoulder joint

11 Epimere fracture of right shin and sprain of right

knee

12 Pelvic fracture, compression fracture of lumber

vertebral body, splenic rupture, retroperitoneal

hematoma, and left femoral neck fracture

14 Pelvic fracture, splenic rupture, perirenal

hematoma, fracture of shaft of left femur, and right

tibial plateau fracture

15 Brain trauma, splenic rupture, fracture of right

shoulder blade, right shoulder joint sprain

16 Left tibiofibula fractures, compression fractures of

lumber vertebral body, and retroperitoneal

hematoma

17 Pelvic fracture, fracture of shaft of right femur, and

left tibial fracture

18 Chest trauma, and fracture of shaft of left humerus,

and right clavicular fracture

19 Pelvic fracture, splenic rupture, right femoral neck

fracture, and fracture of left tibial plateau

20 Brain trauma, fracture of lower shaft of femur, and

right fibula fracture

21 Pelvic fracture, left femoral neck fracture, and right

fibula fracture

22 Chest trauma, fracture of shaft of left humerus, and

right ulna fracture

The criteria of crush syndrome in our group were: over one

hour pressing of the body parts; involvement of large amount

of muscular tissue; development of pallor, clamminess, cold

skin, pulselessness, or shock; and the development of

mani-festations of acute renal failure which are: oliguria less than

400 ml/24 hours, BUN increase more than 40 mg/dl,

creati-nine increase more than 2 mg/dl, serum potassium increase

more than 6 mmol/l, serum phosphorus increase more than 6

mg/dl or serum calcium decrease less than 8 mg/dl Upon

admission, the patients were immediately given interventions

such as anti-shock treatment, alkalifying urine, correcting

water and electrolyte disturbances, diuresis, dehydration, and

infection treatments Twenty-seven patients received

anti-shock treatment, 25 received urine alkalization, 19 received

hemodialysis, 15 received fasciotomy, and 5 received

amputa-tion due to severe infecamputa-tion All patients received

broad-spec-trum antibiotics to control infection and tetanus antitoxin

Acutely increased interaponeurosis pressure in victims of

crush injury can lead to severe muscle necrosis, which

requires surgical intervention Prompt fasciotomy can save

lives and prevent the development of dangerous

complica-tions after crush syndrome Indicacomplica-tions for fasciotomy included

increased turgid of pressed limbs with high tension or/and

local ecchymosis, blister in the skin, symptom of 5 "P" (Pain,

Pallor, Paralysis, Parathesias, and Pulselessness), persistent

urine myoglobin, or interaponeurosis pressure higher than 40

mmHg Hemodialysis is the first choice for crush syndrome

patients complicated with acute renal failure and hyperpo-tassemia Indications for hemodialysis included serum creati-nine level above 8 mg/dl, BUN above 100 mg/dl, serum potassium above 7 mmol/l, serum bicarbonate below 10 mEq/

l, or/and clinical symptoms of ARF, such as edema, hyperten-sion, heart failure, nausea, and vomiting

Monitoring of dangerous complications in patients with crush injury

The most important symptom of crush syndrome is acute kid-ney injury ARF is defined when a patient with crush injury has one of the following symptoms: oliguria (urine output < 400 ml/24 hours), increases of BUN (> 40 mg/dl), serum creati-nine (> 2 mg/dl), uric acid (> 8 mg/dl), potassium (> 6 mmol/ l), phosphorus (> 8 mg/dl), or decrease of serum calcium (< 8 mg/dl) [12,13] We observed the incidence rates of traumatic shock, ARF, acute pulmonary edema (APE), stress ulcer (SU), and multiple-organ dysfunction syndrome (MODS) as well as the vital signs of the patient Besides, we also closely moni-tored the changes of urine output, serum BUN, serum creati-nine, serum uric acid, urine protein, and serum CK, ALT and LDH The decrease in amputation rate and morbidity rate were also used to evaluate the outcomes of patients

Statistical analysis

All the data were expressed as mean ± standard deviation Paired t-tests were used when the difference of pre- and post-treatment was in a normal distribution When the variables did

23 Brain trauma, compression fracture of lumber

vertebral body, pelvic fracture, and right tibiofibula

fracture

24 Chest trauma, fracture of shaft of left humerus, and

right radius fracture

26 Pelvic fracture, compression fracture of

choracic12/√lumber1 vertabral body, splenic

rupture, retroperitoneal hematoma, fracture of shaft

of right femur, and left tibiofibula fracture

27 Chest trauma, fracture of shaft of right femerus,

and left ulna fracture

29 Pelvic fracture, splenic rupture, and fracture of right

femerus shaft

30 Brain trauma, pelvic fracture, left inferior femur

fracture, and right fibula fracture

32 Chest trauma, fracture of shaft of left femur, and

right olecroanon fracture

Table 1 (Continued)

Clinical details of the 32 patients in our group

not have a normal distribution and ranked data, the Wilcoxon

signed rank sum test was utilized All data were evaluated

using a Microsoft Excel 97 spreadsheet (Microsoft Excel,

Seattle, Washington, USA) and SAS9.12 statistical software

Statistical significance was assigned at P < 0.05.

Results

Improvement of laboratory parameters of patients after

intervention

Two weeks after comprehensive treatment, the serum

param-eters of most patients were greatly improved (Table 2) All the

six cases of death had a serum CK level of more than 5000 u/

L; two cases of death had a serum potassium level higher than

6.0 mmol/L, which could not be corrected In the 26 surviving

cases the CK value rapidly decreased to below 1000 u/L

Treatment of complications of patients with crush injury

Of the 32 patients, 18 (56.25%) had traumatic shock, 11 had

ARF (34.38%), 6 had APE (18.75%), 2 had SU (6.25%) and

4 had MODS (12.5%); all 4 patients that developed MODS

died and the other 26 had improved symptoms After pertinent

treatments, the surviving patients had relieved swelling and

distension, and recovered from dysesthesia and anesthesia

Sixteen patients had their dyscinesia symptoms improved and

15 had normal urine output

A particular case in our group worth further discussion was a

15-year-old girl who had tibial and fibula fracture of her right

leg during the earthquake On admission she had a swelled

right leg with fracture blisters on the skin and a decreased

pulse of the dorsalis pedis artery The doctor who first

per-formed the emergent operation for her fractures neglected the

risk of crush syndrome On the next day after fracture fixation,

the girl had an acutely reduced urine output (below 100 ml/24

hours) combined with tachypnea, orthopnea, and

expectora-tion of bloody sputum Auscultaexpectora-tion showed moist rales in

bilateral lungs The heart rate (HR) was 140 to 160 beat/min

and respiratory rate (RR) was 35 to 46 breaths/min Pulse oxy-gen saturation was only 60% Therefore, she was transferred

to our ICU and was diagnosed with crush syndrome accompa-nied by APE She was immediately subjected to ventilation by mask oxygen, intravenous injection of cardiotonic, diuretics and hemofiltration Gradually, the HR and RR of patients decreased and the pulse oxygen saturation was improved

Comprehensive treatment of crush syndrome and the outcome of patients

Seventeen (53.13%) of the 32 patients met the diagnosis cri-terion of crush syndrome Eighteen (56.25%) patients had traumatic shock, 11 (34.38%) had ARF, 6 had acute heart fail-ure, 2 (6.25%) had stress ulcer, and 4 (12.5%) had MODS Six (18.75%) patients died in our group, one due to severe capillary leak syndrome, one due to uncontrolled infection after amputation, and four due to MODS Five (15.63%) patients received amputation due to severe infection of the involved limbs The 26 surviving patients were alive and well three months later The major treatment of crush syndrome included anti-shock treatment, surgical intervention and hemodialysis

In total 18 patients received prompt anti-shock treatment and

12 patients were successfully resuscitated Prompt surgical interventions were given to 15 of the 19 patients who had the indications for fasciotomy; the other four patients did not receive fasciotomy due to severe infection of the wounds Sev-enty-two hours later, the limb swelling was aggravated in one

of the four patients who did not received fasciotomy initially, and several blisters appeared on the local skin, accompanied

by local ecchymosis and decreased artery pulse, indicating increased intramuscular pressure, and fasciotomy was per-formed finally, but the patient died of MODS Eleven (34.38%) patients with proper indications received hemodialyses: all of them had different degrees of ARF symptoms, 5 had hyperpo-tassemia, 7 had anuria, and 4 had combined hyperpohyperpo-tassemia, anuria, and elevated creatinine The mean urine output of the patient rose from 174.5 ± 82.7 ml to 954.6 ± 132.5 ml after

Table 2

Improvement of laboratory parameters after treatment in 32 patients with crush injury

ALT = alanine aminotransferase; BUN = blood urea nitrogen;CK = creatine kinase; LDH = lactate dehydrogenase.

treatment (P < 0.05), and the urine output of 15 patients was

restored to normal levels

Discussion

In this paper we reported the treatment of 32 patients with

crush injury in a front-line tent ICU, which was established near

the epicenter of the Wenchuan earthquake and was equipped

with facilities rescued from the collapsing buildings of a local

hospital Close monitoring and prompt intervention have

helped to save the lives of the 26 patients The tent ICU is of

great significance in saving the lives of patients with crush

injury following a major disaster More attention should be

given to setting up a well-designed front-line ICU for major

dis-asters

Advantages of front-line ICU after an earthquake

A front-line ICU is very important for treatming crush injury

patients after disasters such as an earthquake, because it is

equipped with advanced facilities and first aid materials

needed for critical conditions A front-line ICU, such as ours,

can be located on the site of the disaster, giving treatment in

a timely manner [24-26] It is reported that most victims of

dis-asters and wars died on the spot where they were injured For

example, in a war 40% of the patients died immediately after

injury, 25% died 5 minutes after injury, 15% died 5 to 30

min-utes after injury, and 20% died 30 minmin-utes after injury; it is

indi-cated that timely treatment of these patients is vital A front-line

ICU can provide this timely treatment, relieve the symptoms of

patients, improve their biochemical parameters, and reduce

crush syndrome complications, allowing for surgical

interven-tion of the patients After a major disaster such as Wenchuan

earthquake, there will be a large number of patients with crush

injury When compartment syndrome, ARF and/or other

severe complications occur, the patients need to be sent to

the ICU immediately for closer monitoring A tent ICU near the

epicenter can not only provide timely treatment to the victims,

but also avoid the risks of aggravation of patients' condition

during the evacuation [27,28]

Close monitoring, early diagnosis and treatment of crush

syndrome

There are a large number of crush injury patients following a

major earthquake, and early diagnosis and close monitoring

can lower the incidence of crush syndrome In addition to

mon-itoring the vital signs, more attention should be paid to

observ-ing the patient's blood pressure and changes of urine in order

to make an early diagnosis of crush syndrome Observation of

the color and volume of urine and the urine protein is also a key

step to prevent the transition from crush injury to crush

syn-drome Furthermore, monitoring and correcting hypotension

can prevent ARF in patients with crush syndrome In our ICU,

only limited biochemical parameters were obtainable;

how-ever, close monitoring of the above-mentioned parameters

helped us to make early diagnosis and treatment assessments

Due to the limited parameters we could obtain, observation of

urine output served as an important parameter for diagnosis of patients and for predication of prognosis The serum parame-ter changes caused by muscle necrosis are very important in the diagnosis of crush syndrome Unfortunately, some impor-tant parameters could not be obtained in our ICU due to lim-ited equipment Sophisticated biochemical instruments are essential for a front-line ICU

Reportedly, 7 out of 10 patients with crush injury after a cata-strophic earthquake developed crush syndrome, and 10% of the total casualty number was due to crush syndrome There-fore, prevention and management of crush syndrome are criti-cal to lower the mortality rate The survival rate of our group is 81.25%, greatly higher than that reported previously [29-31] The major differences of treatments between crush injury and other types of traumas include that patients with crush injury need early and prompt expansion of blood volume to guaran-tee renal perfusion, correction of acidosis and relief of limb swelling Most patients with crush injury are in a state of hypo-tension and need intravenous administration of a large volume

of fluids, including artificial plasma, 5% glucose, NaHCO3, aescigenin, and human serum albumin Colloid should be used

to elevate the osmotic pressure and relieve inter-aponeurosis edema; diuretics such as indapamide should be used when circulation is stable Although mannitol is effective in decreas-ing inter-aponeurosis pressure, it was not used in our cohort

to avoid aggravation of renal function; instead, aescigenin, human serum albumin, and indapamide were used in our patients to relieve swelling of the injured limbs

Surgical intervention and post-operation monitoring of patients with crush syndrome

Duman and colleagues believed that prompt fasciotomy in earthquake victims are both life-saving and can prevent some

of the severe and dangerous complications of crush syndrome [3] In fact, not only can close fractures lead to compartment syndrome, but open fractures can also result in it; radical deb-ridement should be performed for open fracture and repeated debridement is needed when necessary Fasciotomy and expansion of wounds should be performed to remove the necrotic tissues to ensure unobstructed drainage The aim of fasciotomy is to prevent muscle necrosis, compartment syn-drome and the need for amputation Those who took a nega-tive altitude toward fasciotomy in earthquake victims thought that resection of a large volume of muscle together with the surrounding tissues would inevitably cause loss of fluid and increase the chance of infection Infection secondary to fasci-otomy and primary trauma of earthquake victims have always been grave challenges in the clinic Ekrem [32] reported that the incidence of severe infection was as high as 37.3% in patients with crush injury Therefore, in a front-line ICU, the sur-gical wounds should be closely observed and anti-infection measures should be promptly taken when necessary In our group, five patients have to receive amputations because of

aggravated distension of compressed extremities,

deteriora-tion of ecchymosis and blister, local skin becoming purple/

black in color, hyperpyrexia and acute increase of leucocytes

Postoperatively, the patients were closely monitored and the

incisions were observed Only one patient of the five died of

uncontrollable infection We believe that surgical intervention

of earthquake victims should be considered for earthquake

victims when the correct indications are strictly followed

Close monitoring of severe complications of crush

syndrome

The common complications of crush syndrome include

trau-matic shock, ARF, acute heart failure, SU, and MODS; early

diagnosis and intervention are vital to the survival of patients

In our group, the incidence rates of the aforementioned

com-plications were similar to those reported previously [33-35]

In our front-line tent ICU, energetic anti-shock measures were

taken for 18 patients who had traumatic shock to avoid the

development of crush syndrome, because many severe fatal

complications develop due to long periods of shock SU is a

common manifestation at the final stage of patients in shock

and often develops under stress The incidence rate of SU

was reportedly about 4% to 10% in trauma patients [36,37]

Two of our patients suffered from SU The result indicated that

it was necessary to adopt early active mental intervention to

relieve the mental stress The most severe complication of

crush injury is MODS Four of our patients developed MODS

and all died So it is especially important to monitor the

func-tions of major organs to prevent MODS in the front-line ICU

Experience with the 15-year-old girl indicates that APE can

also be the first clinical manifestation of crush syndrome; and

the necrosis of leg muscle as well as that of the huckle (the

part of the leg close to groin) can lead to crush syndrome

[38-40]

Eleven of our 32 patients had ARF, a dangerous manifestation

of crush syndrome Hemodialysis is the best choice of

treat-ment for ARF and prevention of crush syndrome It is reported

that hemodialysis can keep the incidence of internal

environ-ment disorder and other complications to a minimum The

urine output recovered to normal levels in 11 patients who

received hemodialysis Our ICU only had one hemodialyzer, so

patients could not receive continuous hemodialysis and four of

our patients developed MODS and died Advanced portable

biochemical analyzer in the front-line ICU allows for close

mon-itor of patients with crush injury, and a blood dialyzer can give

prompt, effective treatment to patients who's condition is

com-plicated with ARF [41,42] When rescuing after a disaster

such as the Whenchuan Earthquake, more portable

hemodia-lyzers should be deployed to provide prompt treatment of

patients with crush syndrome

Conclusions

Severe crush injuries and their life-threatening complications such as crush syndrome are common after a major earthquake like the one that occurred in Wenchuan The establishment of

a front-line ICU close to the epicenter of earthquake allows for

a prompt on-spot monitoring and rescue of critical patients suffering from severe traumatic injury, which can decrease the mortality rate and complications in patients with severe crush injury, avoid amputation, and should be encouraged

Competing interests

The authors declare that they have no competing interests

Authors' contributions

WL was responsible for data collection, analysis and writing the manuscript JQ, XL, and QZ participated in data collection and analysis LW and DC participated in the data collection and revising the manuscript ZL was responsible for the overall design of the manuscript All the authors have read and approved the submission

Acknowledgements

Written consent for publication was obtained from the patients or their relatives The authors thank Danghui Yu from the Second Military Medi-cal University for polishing the English language of the manuscript.

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• Six (18.75%) patients died in our group, one due to severe capillary leak syndrome, one due to uncontrolled infection after amputation, and four due to MODS Five (15.63%) patients received amputation due to severe infection of the involved limbs

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